Management of the Patient with Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

Patient Discussion: Potential Harms of ACEIs

You then discuss the possible risks of adverse effects from taking an ACEI, so that the patient can weigh the benefits and harms with you to determine an appropriate decision. You explain that research has found that he may experience:

Discussion of answers:

A. Incorrect. The addition of ACEIs to standard therapy for stable ischemic heart disease patients increases the risk for syncope, cough, and hyperkalemia.

B. Incorrect. According to available research, the risk of hypotension is similar with ACE inhibitor therapy vs. placebo in patients with stable ischemic heart disease.

C. Incorrect. The addition of ACEIs to standard therapy for stable ischemic heart disease patients increases the risk for syncope, cough, and hyperkalemia.

D. Incorrect. According to available research, ACE inhibitors reduce the need for future revascularizations better than placebo in patients with stable ischemic heart disease.

E. Correct. There is low level evidence that the addition of an ACEI to standard therapy for patients with stable ischemic heart disease increased their risk of syncope, cough, and hyperkalemia. However, adverse event reporting was not consistent across trials. Several trials included pre-randomization run-in periods where candidates who were intolerant to the study drug were excluded. This may limit the applicability of the harms data for the overall stable ischemic heart disease population. Nonetheless, the frequency of these adverse events was relatively low across all trials evaluated: syncope (2.1%), cough (15%), and hyperkalemia (5.7%). Angioedema occurred at a rate of 0.1% in the trials evaluated and is a potentially serious adverse event. A 2007 AHRQ review of ACEIs and ARBs states that angioedema, a rare but potentially serious reaction, had been reported in several studies. Patients who are or may become pregnant while taking ACEIs or ARBs should also be made aware of the risk of birth defects caused by these drugs.